Growing Capable Parent Consent Form

Growing Capable Playgroup Intake Form

Fill in the below sections to book into our developmental play group.
Childs First Name:*
Childs Last Name:*
DOB:*

DayMonthYear
Parent/Guardian Name:*
Phone Number*
Format: 0000000000.
Email:*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preschool/ School

Rows Name Days attending

School/ Preschool
What are your child's strengths?*
What are your concerns for your child's development?*
Does your child have any medical or disability diagnosis?*
Does your child see any other medical or allied health professionals?

Name / OrganisationPhone / Email
Alternate contact

Name / RelationPhone / Email
Does your child take any medications?
Please click on the following links to review our CKSC Privacy & Confidentiality Policy:

Privacy Policy
I acknowledge I have read and consent to the CKSC Privacy Policy (found on the above links)
YesNo - Please liaise with only the nominated parent/guardian on this form
I consent to photos being published on social media (Facebook, Instagram and our monthly newsletter)I do not consent for photo's to be published on any media platforms
I do not require a private roomI require a private room

Rows	Name	Days attending
School/ Preschool

Form completed by:*

Rows	Name	Relation	Date
1.

NOTE: Please advise us immediately if there are any court orders in place or if there is anyone specifically we are not to discuss your child's sessions with.
Should be Empty:

Growing Capable Playgroup Intake Form